Literature Collection

OBJECTIVES: Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders. METHODS: A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care. RESULTS: We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers. CONCLUSIONS: A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care.

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.

Background/Objectives: Pediatric chronic pain requires individualized care. The Pediatric Pain Screening Tool (PPST) allows for stratification of psychosocial and physical risk factors and may guide targeted interventions. However, its integration into multimodal physiotherapy programs remains unexplored. This exploratory feasibility case series study evaluated a PPST-guided, risk-stratified multimodal physiotherapy intervention in children aged 8-17 years with chronic pain. Methods: Participants were classified as low, medium, or high risk. Interventions were tailored accordingly. Outcomes were assessed pre- and post-intervention and included pain intensity, pain interference, psychological distress, and quality of life. Results: Ten participants (mean age = 13.5 years; 60% girls) were included. Six were classified as high, three as medium, and one as low risk based on the PPST. After an 8-week physiotherapist intervention program, pain interference significantly decreased (MD = -7.5; p = 0.040; d = 1.69), as did pain intensity at rest (MD = -3.1; p = 0.002; d = 2.60) and during movement (MD = -3.0; p = 0.004; d = 2.55), exceeding the MCID of 1.92. In the high-risk group, reductions were observed in anxiety (p = 0.006; d = 2.36), pain-related worries (p = 0.001; d = 3.79), fear of movement (p = 0.015; d = 1.62), and fear of pain (p = 0.002; d = 3.37). Eighty percent reported feeling "a great deal better" in the PGIC including all high-risk participants. Conclusions: These results supports the feasibility of integrating PPST risk stratification into multimodal management, providing a structured and effective framework for addressing pediatric chronic pain.

BACKGROUND: While buprenorphine/naloxone (B/N) is approved for opioid use disorder treatment, effective delivery of B/N comes with significant challenges. Most notably, many patients do not take medication daily as prescribed; this non-adherence worsens treatment outcomes, increases healthcare costs, and leads to persistent worries of diversion among providers and policymakers. The present study examines the feasibility, usability, and acceptability of MySafeRx-a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing designed to address the challenges of office-based opioid treatment (OBOT) with B/N. METHODS: The MySafeRx platform integrates electronic pill dispensers, text-messaging, and videoconferencing to provide supervised self-administration of medication and daily motivational coaching through an Android app interface. High-risk early adults (18-39 years old) who were enrolled in OBOT with B/N and had documented illicit opioid use in the past month during opioid agonist therapy (n = 12) participated in a 28-day single-arm observational study of the MySafeRx platform in addition to standard care. RESULTS: Two-thirds of participants who completed the study achieved an average of > 5 days per week of supervised B/N self-administration. Visual confirmation of medication adherence was demonstrated for an average of 72% of study days among all participants. All participants achieved platform technical proficiency within 60 min, reporting good levels of usability and acceptability. Illicit opioid abstinence rates confirmed by urine toxicology increased by 53% during MySafeRx but fell 43% within 3 weeks post-intervention. CONCLUSION: The MySafeRx medication adherence and remote coaching mobile platform is acceptable and can be feasibly implemented in real-world opioid use disorder treatment settings during high-risk periods (i.e., initial stabilization, after illicit opioid lapse), resulting in reduced illicit opioid use; however, the effect did not last after intervention completion, suggesting longer duration or extended taper of program may be needed. ClinicalTrials.Gov NCT02942199 10/24/16 https://clinicaltrials.gov/ct2/show/NCT02942199.